肩關(guān)節(jié)前脫位anteriorshoulderdislocation課件

1、Acute anterior dislocation of the shoulder,AnatomyStability: - ball & socket = compression in concavity effectBone - big head – small cup = unstableMenisci - labium

2、 = ↑ depth of cup by 20%Ligaments - glenohumeral & capsuleMuscles - rotator cuff & biceps = holds ball in cupPrimary Movers - Deltoid, Pec. major & Lat. Dorsy=

3、subluxing forces Dynamic - proprioceptive feedback,Pathophysiology (Lazarus 1996)Chondro-labral defect causes a 65% reduction in stability in the direction of the defectDeficiency of the ant. inf. capsulo

4、labral complex Fracture of ant. lip of glenoid = 15%Detachment of labarum/capsule = 15%Tear of glenohumeral ligaments = 54%Avulsion of subscapularis and ligs of humerus (HAGL) To prevent the persistence of the de

5、fect it needs to be repairedArthroscopically Open,Acute InjurySomething breaks or tears and therefore can be repaired.Repair is better than reconstructRepair is easier than reconstructChronicInstability has addi

6、tional plastic deformation of the capsule and glenohumeral ligaments therefore needs to be shortenedRestoring the normal functional anatomy is impossible,Conservative TreatmentRowe – JBJS, 1957324 young patient with a

7、nt. dislocations94% had recurrence if 40 years oldBurkhead & Rockwood (text book)40 patients with acute dislocation & vigorous rehabilitationOnly 16% had good or excellent result (1 in 6)Deny & Drew –

8、 Injury, November 200221% of all patients presenting with shoulder dislocation had previous dislocation in 1 year43% in patients 15-22 years had re-dislocations,Non operative treatment of shoulder dislocation in young

9、 athletesArciera – J Arthroscopy, 1995De Beardino – J South Orthopaedic Ass, 1996Haelen – J Arch Orthopaedic Trauma Surgery, 1990Hovelius – J Orthopaedic Science, 1999Wheeler – J Arthroscopy, 1998Kirkby – J Arthro

10、scopy, 1999 all over 80% recurrence rateNon operative treatment is unacceptable,Prospective Randomised Study Bottani etc.–Military Personnel Medicine Vol 30 No 4 2000First Time Acute Traumatic Shoulder Dislocation

11、Stabilisation V’s Non Operative: Follow up in 36 months24 patients aged 18-26y. 14 Non Operative – rehab immobilised 4 weeks9 of 12 non operative had instability (75%) (6 open Bankart repair)10 ASC Bankart repair

12、with bioabsorbable tack <10 days1 of 9 operated patients had instability (11%),Comparison of Arthroscopic & Open StabilisationSample SizeFollow UpRecurrenceASCOpenASCOpenASCOpenSteinbeck 199830

13、323640175Field 19995050333080Cole 199937225255169Hayes etc 199944132929124ConclusionArthroscopic repair for chronic instability is inferior to open repair? Due to plasti

14、c deformation,Chronic anterior instability,Arthroscopic Techniques for Primary Dislocations1982 Johusa – with staples1987 Morgen & Badenstab – transglenoid sutures1991 Caspari -Cannulated bio-absorbable tacks 19

15、93 Wolf & Snyder – suture anchors = difficult1989 Wheller - ASC staple1993 Gohlke - Suture anchors1994 Arciera - ASC transglenoid1996 Speer - Bio-absorbable tack1999 Wintzell - ASC lavage2000 Introduction of a

16、multitude of new gadgets & anchors,Arthroscopic RepairsEinoder, 1984 Knee ClubDescribed Arthroscopic transglenoid sutures using:K wire with eye (ACL) introduced via anterior portalSucking tubeSutures tied

17、 over infraspinatus fascia or spine of scapula Results4 out 5 patients returned to the same level of sport with no re-dislocations,Arthroscopic Repair,Boszotta & Helperstorfer – Arthroscopy, July 2000 Transglenoid

18、 suture repair for initial Ant. dislocation72 patients (1988-95)61 ♂ 11 ♀Aged 19-3934% = Bankart lesion (6 with bone)66% = Avulsion of capsulolabral complexResults7% = Redislocation all due to trauma (severe in

19、 2 out of 5)85% = Returned to unrestricted pre injury sporting activities,Randomised StudiesAsc. Stabilisation V’s Non OperativeArciera et. al. – A.J. Sports Med., 199432 military men with acute 1st up dislocation, A

20、verage of 32 months follow up15 patients – non operative – 80% redislocated21 patients – transglenoid suture – 14% redislocatedBottony & Wilkings etc. A.J. Sports Medicine 2000Patients with acute traumatic fi

21、rst time shoulder dislocation14 young patients – non op, 75% redislocation10 young patients – Asc. Bankart repair, 10% redislocation,Asc. stabilisation Dara & Gerber – Journal of Shoulder & Elbow, 200020

22、shouldersAv 3 year follow upRecurrences occurred in patients who were chronic dislocators i.e. <30%Therefore now do open surgery for recurrent dislocationsAsc. surgery for acute dislocationsDe Beardino et al –

23、 An J. Sports Med., 200049 1st up acute post traumatic Shoulders dislocationAverage 37 months follow up Tack anchor.6 Patients re-dislocated (13%) +4 had open surgery,Bozzotta & Helpastorger (Austria) – J. Arthro

24、scopy, 2000 Arthroscopic Transglenoid Suture Repair for Initial Ant. Shoulder Dislocation72 Patients61♂ 11♀ - Sporting ambitious patients25 Patients Bankart lesion (6 with bone)43 Patients Capsulolabral

25、avulsionResults5 patientsRe dislocated 2 had significant trauma3 had insignificant trauma = 4%Therefore results of primary repair are better than surgery for recurrent dislocationBut transgleniod repai

26、rs are obsolete,Against …Arthroscopic RepairRoberts, Taylor, Brown, Hayes, Saies (Adelaide)Journal of Shoulder & Elbow, September 199956 acute 1st up shoulder dislocations2½ year post operative and return

27、to Australian Rules FootballOperations:Asc. suture repair – 70% recurrenceAsc. Bankart repair with tack – 38% recurrence,..Open repair & copsular shift – 30% recurrenceTherefore Asc. treatment alone not good e

28、nough,Cole & Warner – Clinical Sports Medicine 2000 Arthroscopic V’s Open Bankart RepairFor Traumatic Anterior Shoulder Instability% Asc. treatment modalities are increasing due to:Better understanding of the pa

29、thophysiologyBetter pre operative evaluation of the injury (i.e. patient selection)New surgical techniquesBetter instrumentationBetter anchors,Protocol for Acute RepairMature & active person15 to 50 years oldF

30、irst episode of glenohumeral dislocationReduced on field, first aid, club Dr or DEMExamination & X-rayInformed consent – time off work - outcomeExamination under GAASC of glenohumeral joint, check rotator cuff

31、as wellAcute repair of all demonstrable tears or fractures ? restore normal anatomyRehab activity – collar & cuff, physiotherapyAvoid ext. rotation and abduction for 6 weeksReturn to contact sport in 12 weeks,I

32、nvestigationsPlain x-raysCT scans if complicated associated featureMRI rarely – get more information from Asc.Examination Under GASupine load shift test with arm at 80° abducted compared with normal shoulder

33、1+ball to rim2+ball riding over rim with spontaneous reduction3+ball stays dislocatedArthroscopy,Patient PositionGeneral Anaesthetic Beach Chair with arm held by assistantLateral position with arm in traction

34、& shoulder abductedShoulder examined, degree & direction of instability notedPortals = 2 or 3Posterior portalAnt. sup portalAnt inf portal (occasionally) Injury assessed & debridedRepair method select

35、ed,Arthroscopic Repair Procedure,RehabilitationMinimal in first 4 weeksNo ext rotationAbduction less than 45°Pendulum exercisesIsometric resistance exercisesGraduated in 4 – 8 weeks ↑ ROMGraduated weig

36、ht trainingReturn to sportNon contact = 6 weekscontact = 12 weeks,Arthroscopic V’s Open Bankart RepairAdvantagesAccurate diagnosis of all structuresLess morbidity/painSmall scarsFaster recoverySooner return to

37、 activitiesLess restriction of movementDisadvantagesNeed all the equipmentTechnically demandingLong learning curveLack of versatilityHigher failure rate arthroscopic = up to 33% - open = less tha

38、n 10%,Stern Jozrawi Rastolazzi – Arthroscopy Oct. 2002Advantages V’s Disadvantages of Asc. RepairAdvantages↑ cosmesis↓ morbidity↓ stiffnessEasy revisionDisadvantages1) Reluctance to refer patient immediat

39、ely2) Difficult operation3) Expensive instrumentation4) Biological healing time is not accelerated5) Same post operative restrictions,ProblemsDifficulty convincing Club Trainers, Physicians, sporting club Docto

40、rs & DEM staff to refer the young athlete within 2-3 days.Time consuming discussions convincing patient to have the operation rather than early return to sport.No problem advising a recurrent dislocators to have a

41、 stabilisation procedure at the end of a sporting season.Mostly after hours surgery with staff who are not familiar with the operation and instrumentation.,Arthroscopy of Shoulder1935 – Japanese Surgeons arthroscoped

42、, shoulders 1960s – Curiosity activity in the western world1970s – Diagnostic Asc. examination è open surgery1980s – Simple Asc. techniques èfor simple problems1990s – ↑ Instrumentation & tacks 

43、2; more tried it.2000s – ↑ Techniques & anchors – Can be done by any surgeon skilled in arthroscopic techniques,Shoulder reduced on field, first aid room or DEM then referred Treatment History

44、1970s -Conservative for all 1st up unless fractures with Bristows or Bankart repair for recurrences1980s -Asc. transglenoid suturestied over spine of scapula or muscle fascia1990s -patient in lateral po

45、sition with arm in tractionor patient in Beach chair position multiple, tacks and suturessurtac screw tack anchors etc.2000 -better anchors and sutures have made the procedure available for all surg

46、eons experienced in arthroscopic technique,Acute Labral Tear,Acute Repair of Anterior Labral Tear,ConclusionAsc. repair of the Capsulo-ligamentous injury to the shoulderis a simple procedure for a surgeon skilled

47、in arthroscopic technique Chronic instabilities have associated plastic deformity of the tissues that need to be addressed and this makes the result of a simple procedure unpredictable.An ac